7. Oxygenation and Ventilation A decrease in ventilation = a decrease in oxygenation...usually . For example, the lungs require ventilation to move the CO2 out of the body, but a hypoventilating patient with a NRB on will have increased carbon dioxide AND increased oxygen. Not ideal.

9. Clinical Assessment Oxygenation Pink skin, mucous membranes and nail beds Mental status Pulse oximetry Ventilation Depth of respiration Respiratory rate Mental status Capnography General Positioning (Tripod); Ability to speak

10. Tripod position Respiratory retractions Perioral cyanosis

11. Auscultation The lungs are divided into lobes. The right lung has three lobes while the left lung only has an upper and a lower lobe. The upper lobes of the lungs are more anteriorly placed while the lowers are placed more posteriorly.

12. Auscultation A minimum auscultation includes bilateral checks of both upper and lower lobes, a four point listen. Listen to the uppers at just below the clavicles bilaterally. The lowers are best heard from the back, however patient's cannot always sit forward for you. If so, then listen to the lowers @ midaxillary, just below the armpits, bilaterally. If you are able to listen through the back, auscultate at points around the scapula. LS: CTA x4

13. Auscultation

14. Auscultation Crackles or rales - A fine, bubbling sound heard on inspiration and associated with fluid in the smaller bronchioles. Secondary to CHF/ pulmonary edema, drowning, or an acute cardiac event. Wheezes – A musical squeaking or whistling sound heard more on expiration, but can also be heard on inspiration. Secondary to bronchospasm associated with asthma, COPD, pneumonia, or allergic reaction. Types of lung sounds:

15. Auscultation Rhonchi - A coarse bubbling or plopping sound heard on inspiration or expiration. Can be emphasized by having the patient exhale forcefully. Secondary to pneumonia. Stridor – A high-pitched noise heard while inhaling during a partial airway obstruction. Secondary to FBAO, or laryngospasm.

16. Respiratory Distress – having difficulty getting oxygen into lungs and into blood Respiratory Failure – unable to take in enough oxygen to meet body's needs Respiratory Arrest – no longer breathing

17. Do I need to intervene? Is the patient adequately oxygenated? Is the patient adequately ventilated?

18. Five Reasons to Intervene

24. Oxygenation Interventions Acute mask: Flow rate @ 4-8 lpm Non-rebreather: Tighten the seal around the nose and with the elastic band, otherwise it only provides maybe 60% O2. 10-15 lpm, enough to allow the reservoir bag to reinflate between respirations. Bag Valve Mask (BVM): With a tight face seal. BVM is a 2-3 person job optimally. 10-15 lpm.

25. Ventilation Interventions Positioning : Sniffing postion is a position where there is slight flexion of the neck and extension of the head. This position is sometimes helped by placing a folded sheet or towel underneath the patient's occiput. For children, the occiput is much larger than an adult's and will cause enough flexion in the neck to crimp off the softer airway of the child. Place a folded sheet or towel under the child's shoulders to raise them up. Jaw thrust is the position for trauma patients.

26. Jaw Thrust Head Tilt/Chin Lift

27. Ventilation Interventions Airway Adjuncts : Always use! If the patient can tolerate an oral airway, use it. If the patient cannot tolerate the oral airway, place a nasal airway. It is A-OK to place TWO nasal airways and an oral airway in a difficult to ventilate patient in order to maximize the airway.

28. Ventilation Interventions BVM Ventilations: Use the C-E position with the hands. BVM is a two person job, use two people if there is enough manpower.

29. Two-handed Techniques

30. In order to do it properly, one-person BVM ventilation requires a substantial amount of Practice and Experience

31. Ventilation Rates: Adults 10-12 breaths/minute or a vent q 5-6 seconds Pediatrics 12-20 bpm or a vent q 3-5 seconds Adv airway rate 8-10 bpm

37. A Word on Aspiration Aspiration is the active inhalation of stuff into the airway (stuff = vomitus, saliva, blood, etc) Pulmonary aspiration secondary to vomitus can be disastrous. The acidity of the gastric acid can destroy lung surfactant and cause alveolar collapse. It can fill up the alveoli and bronchi with fluid, causing pulmonary edema, hypoventilation and hypoxemia. These patients have prolonged recovery times and much higher mortality rates.

38. Removing jewelry may or may not be feasible

45. LMA (Laryngeal Mask Airway) Advantages : BLS level advanced airway; minimal spinal movement is required for insertion Disadvantages : The patient must be unresponsive and have no gag reflex; not all pt's can be adequately ventilated with the LMA; the airway must be removed when the pt becomes responsive, agitated or vomits; the airway should be replaced with an ET tube as soon as possible Contraindications : Presence of a gag reflex; caustic ingestion; esophageal trauma or disease

47. Make your first attempt your Best attempt!

48. Advanced Airway Confirmation Confirm placement with at least four measures, recorded on your PRF: Bilateral breath sounds and Absence of epigastric sounds (5 point check) ETCO2 SPO2 Equal chest rise and fall Condensation in the tube Direct visualization of placement (ET)

49. The LMA sits in the esophagus and closes it off, allowing ventilations through the larynx.

50. FBAO Foreign Body Airway Obstruction inevitably leads to cardiac arrest in all patients if not corrected within minutes. Incomplete obstruction : No heimlich, encourage pt to clear obstruction themselves Complete obstruction : Heimlich maneuver until person loses consciousness

51. FBAO Unconscious choking : Rescue breathing and CPR, checking for the foreign object each time you open the airway. No blind finger sweeps. Continue until advanced procedures become possible (magill forceps with laryngoscopy, or cricothyrotomy)

52. End Tidal CO2 End Tidal CO2 is an objective measurement of the quality of ventilation and perfusion. It records carbon dioxide both as a waveform and as a numerical value. Use of ETCO2 with advanced airways reduced Orlando, Florida's misplacement percentage from 25% to 0%!

53. End Tidal CO2 The orange bit of the ETCO2 line plugs into the top-left of the lifepak, above the SPO2 input.

54. End Tidal CO2 The nasal prong line measures CO2 through a flap that hangs over the mouth. It also can deliver oxygen to the patient. The advanced airway line connects to the top of the LMA or endotracheal tube. The line can become clogged and un-useable if the patient vomits.

55. ETCO2 The waveform does not automatically show up on the screen, you will need to spin the dial to highlight the bottom section, then switch the waveform to CO2. Have a play with the monitor next time you are on shift.

56. Just wanted to show y'all a Really Big Truck!

57. And also a truck for really big people!